Exploring how, with skill and experience, nurses are able to empower clients through one-to-one interventions to improve their sexual health
Barnes, J. (2009) Health promotion in sexual health 2: nurses’ role in engaging with clients. Nursing Times; 105: 19, early online publication.
This is the second in a two-part unit on health promotion in sexual health. Part 1 outlined various theories and models on the issue. This part examines the factors that contribute towards successful health promotion, such as an effective communication style. It outlines how nurses can put health-promotion theory, competencies and guidance into practice.
Keywords: Sexual health, Health promotion, Communication, Client engagement
- This article has been double-blind peer reviewed
Jayne Barnes, BSc, DipHE Midwifery Studies, RGN, is contraceptive and sexual health nurse, contraceptive and sexual health service, Stockport PCT.
- Identify an appropriate communication style for addressing health promotion issues in sexual health services.
- Understand the four aspects of health promotion in sexual health care.
This article examines how nurses can implement health promotion in practical terms. It discusses activities in relation to the RCN’s (2004) competency framework (currently being updated) and nursing practice.
Health promotion has an important role in sexual health care because it is the route towards empowering people to use measures to prevent unplanned pregnancy and sexually transmitted infections (STIs).
A further aim of health promotion is to help clients make autonomous and non-regretted choices about sexual activity. Well-implemented, successful health promotion is likely to prevent future morbidity for both presenting clients and the wider population.
Health promotion is one of five key competencies specifically identified for sexual and reproductive health care (RCN, 2004). Within this framework, the topic is separated into four key areas. These are:
- Information and education;
- Prevention and risk reduction support;
- Skills building;
- Partner notification (RCN, 2004).
The accommodation provided for clinical services is an important consideration for clinicians, managers and commissioners for various reasons.
A private and soundproof room enhances communication during the consultation (French, 2006) and is likely to promote client confidence when disclosing personal information. This, in turn, is likely to have a positive impact on the health promotion process.
An effective communication style used throughout the consultation maximises the interaction’s success and the associated health promotion.
This process starts at the initial greeting. Nurses should work on their communication style, maintaining eye contact (French, 2006) and show interest in clients’ individual concerns from the start of the consultation. By doing this, they are likely to maximise their success in addressing presenting concerns or meeting clients’ needs.
Nurses should take a history appropriate to clients’ needs and which fits in the ethos of their particular service, without probing unnecessarily.
Clients’ needs should be met ‘in a non-judgemental and supportive way’ (Gould, 2008). It is also important to actively engage them by asking questions and checking their understanding at regular intervals, in an encouraging and inclusive manner.
All this lays the foundation for positive communication during health promotion.
To maximise communication and client comfort, ideally one professional should deliver the full consultation. Nurses should refer clients to medical staff as appropriate, ensuring they work within their own competency.
Practitioners working in sexual health deal with a variety of clients with various needs.
They often carry out first consultations, with no background knowledge of them.
It is extremely important that nurses have good assessment skills and are able to recognise situations where specific communication tools are needed. Some clients may need a translator or have specific needs in terms of their mental capacity (Office of the Public Guardian, 2007).
Nurses should also be aware of groups that are identified as being at high risk of STIs or bloodborne viruses (see Fig 1).
Nurses’ engagement with clients
Services that deliver integrated contraception and STI screening and treatment offer an excellent opportunity for nurses to maximise their engagement with clients, by developing rapport throughout the consultation.
In this instance, nurses have a valuable role in validating the possibility that unwanted pregnancy or catching an STI could become reality. In this way, they ensure clients acknowledge the ‘health threat’ described in theory (Conner and Norman, 2005a).
Nurses should also impart accurate information and education, thereby fulfilling this aspect of the RCN’s (2004) competencies. This could act as the ‘cue’ that stimulates clients to change (Abraham and Sheeran, 2005). This would start the process of prevention and risk reduction support (RCN, 2004).
With skill and experience, nurses can positively build clients’ individuality and self-worth. The example below shows how nurses can achieve this:
Client: ‘I’ve come for infection testing and contraception… should have come before….’
Nurse: ‘You are here now… It is good to test for infections and start some contraception.’
Client: ‘I don’t know why I have been having so many one-night-stand sexual partners.’
Nurse: ‘You are right to test for infections…. You don’t need to blame yourself…. Let’s have a think about why you have done that and what you could do to change and move forward now.’
The ‘prevention and risk reduction support’ discussion could explore what clients can do to use self-protection measures such as hormonal contraception.
This could centre on helping them to identify their chosen method of contraception, focusing on its acceptability to them. It would also involve promoting a barrier method for STI protection. Discussion could explore clients’ beliefs, motivations and intentions about condom use.
A positive attitude and effective communication style (described above) can greatly enhance the interaction. An approach that builds empowerment and autonomy should be used and the appropriate health-promotion messages threaded through the consultation, ending with a positive message for individual clients.
Through this discussion, nurses are actively incorporating ‘skills building interventions’ (RCN, 2004) into the consultation. This could focus on how to negotiate condom use or a condom demonstration.
Both prevention and risk reduction support and skills building interventions relate to recommendations in NICE (2007) guidance on reducing STIs and under-18 pregnancies (Fig 1).
This guidance is intended for a range of professionals involved with sexual health directly or indirectly. For nurses, it is a very useful and important document.
In terms of health promotion, recommendations range from identifying clients who are at risk of unplanned pregnancy or STIs, to partner notification and structured risk reduction discussion.
This process could be further developed by translating theory (Conner and Norman, 2005b) into practically focused guidance for professionals.
Nurses should take every opportunity to congratulate clients on their good practices, such as the appropriate use of condoms.
However, clients may need further support, in the form of a risk-reduction programme, to achieve good practices. Nurses would then have a role in identifying those who would particularly benefit from this intervention.
They should be aware of local care pathways for clients in need of more complex health promotion, such as a specific programme. Referral systems may need to be devised or developed to achieve effective care. This care should be available for vulnerable people, as well as for those who think they need specific help (such as that provided for smoking cessation).
Partner notification, the fourth dimension of health promotion (RCN, 2004), should be discussed when an STI is diagnosed. It is the process by which current or previous sexual partners may be informed that they have been in contact with an STI and need treatment.
Clients may notify partners themselves or the process can be done anonymously by service providers. It is a key element in preventing onward STI transmission and nurses are ideally placed to have conversations about this element of health promotion.
Clients often need encouragement to tackle this but, with the approach suggested above, nurses can often successfully promote this activity. The issue can be threaded through the consultation, focusing on it at the end.
Timing and teamwork
Health promotion is often delivered towards the end of the consultation. However, it is an important aspect of care which, if implemented effectively, could prevent future morbidity in clients and their sexual partners.
There are potential barriers in terms of pressures on consultation times, staffing levels and clients’ interest. For this reason, it is important that clinic systems are as efficient as possible, so the whole clinical process can flow smoothly.
Teamwork is important in any clinical setting and is particularly important for providing health-promotion advice. Clients need clear, simple messages and information about sexual health issues and STIs.
Teamwork is also important in terms of clinical governance (RCN, 2003) and it is important that high-quality care is not only planned but also achieved and maintained.
The Medical Foundation for AIDS and Sexual Health (2008) recognised the need for investment in sexual health promotion, alongside a range of aspects of sexual health, with particular emphasis on addressing local needs.
It is vital that nurses, along with clients or service users, are consulted when devising local health-promotion initiatives. Using this client-focused, ‘bottom-up’ approach is much more likely to be successful.
However, in the case of hard-to-reach and vulnerable clients, this presents a great challenge because of their specific needs and the potential difficulty for professionals to successfully reach and engage them.
Sexual health promotion is not just about handing over a bag of condoms.
While practitioners such as nurses are clearly well placed to deliver one-to-one interventions in health promotion, they need appropriate training and experience in communicating with clients and in health promotion.
Nurses also need to be aware of the influence of their communication style in this process, and the need for diplomacy and patience at times.
Translating theoretical concepts into more practically focused frameworks would help to bridge the gap between theory and practice and therefore improve the health-promotion process.
In terms of health-promotion provision, nurses need the time and resources to be able to do this in practice. It is also important to take a team approach and that local referral pathways are devised and put into practice. Nurses’ involvement in planning health-promotion initiatives could be a positive influence.
Including effective health promotion in sexual health is an area that needs commitment at all levels. It is a challenge to sexual health care commissioners, provider services and professionals.
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Abraham, C., Sheeran, P. (2005) The health belief model. In: Conner, M., Norman, P. (2005) Predicting HealthBehaviour. Maidenhead: Open University Press.
Conner, M., Norman, P. (2005a) Predicting health behaviour: a social cognition approach. In: Conner, M., Norman, P. (2005) Predicting Health Behaviour. Maidenhead: Open University Press.
Conner, M., Norman, P. (2005b) Predicting Health Behaviour. Maidenhead: Open University Press.
Gould, J. (2008) Foreword. In: Medical Foundation for AIDS and Sexual Health (2008) Progress and Priorities –Working Together for High Quality Sexual Health. Review of the National Strategy for Sexual Health and HIV. London: DH.
Medical Foundation for AIDS and Sexual Health (2008) Progress and Priorities – Working Together for HighQuality Sexual health. Review of National Strategy for Sexual Health and HIV. London: DH.
NICE (2007) One to One Interventions to Reduce the Transmission of Sexually Transmitted Infections (STIs)Including HIV, and to Reduce the Rate of Under 18 Conceptions, Especially Among Vulnerable and At Risk Groups. London: NICE.
Office of the Public Guardian (2007) Mental Capacity Act (2005) Code of Practice.
RCN (2004) RCN Competencies: Sexual Health Competencies: an Integrated Career and Competency Frameworkfor Sexual and Reproductive Health Nursing(currently being updated) [chk]. London: RCN.
RCN (2003) Clinical Governance: an RCN Resource Guide. London: RCN. http://tinyurl.com/clinical-governance